AARF PA Medical Grant Application Form
Guidelines

Clients can apply for medical funding in the following instances:

1. An AARFPA partner vet has examined the animal and has determined in said vet’s sole and absolute discretion that medical treatment and/or surgery is required for the animal to achieve or maintain an acceptable quality of life.
2. Financial hardship will prevent the owner from following the recommended course of treatment and/or surgery.

Requirements

1. The owner, including spouse or joint owner, has applied for Care Credit and has been declined and they have exhausted all other sources of assistance (credit cards, friends, relatives, etc).
2. The owner must be willing to complete AARF’s “Financial Checklist” and/or submit the previous year 1040 tax form for all adults responsible for caring for the animal, statements of current income and any other documents showing proof of financial hardship (proof of the following benefits: Medicare, Medicaid, Social Security, Disability, Unemployment and or Public Assistance)
3. The prognosis after surgery or treatment must be fair or better, as determined in the sole and absolute discretion of an AARF PA partner vet. The prognosis must include a predicted survival rate of 50% or better for survival beyond 6 months.
4. The animal must be spayed or neutered. If not, it will be done at the time of surgery if the vet determines that it will not jeopardize the health of the animal. If it cannot be done at the time of surgery, the owner must agree to have the pet sterilized within a set time frame.
5. The owner must contribute toward the cost of care in an amount to be determined by AARFPA and its partner vet, payable in the form of an advance deposit prior to the recommended treatment or surgery being performed.
6. The person applying for assistance must be the legal owner of the pet.
7. The owner must agree to abide by any and all follow-up care and treatment recommendations of an AARF PA partner vet.
8. Any of the above requirements can be amended, modified and/or waived at any time in the sole and absolute discretion of AARF PA.


What DOES NOT qualify?

1. We will not pay for any outstanding balances or costs incurred prior to approval.
2. We will not pay for any preventative care, vaccines, or elective surgeries such as declaws, tail or ear docks, dewclaw removal, etc.
3. Any animals owned by a breeder or used for breeding purposes.
4. Any treatment that is the result of neglect or mistreatment of the animal, unless the owner agrees, in writing, to relinquish ownership of the animal and not to own any other animals.
5. Any treatment considered “heroics." We will make every reasonable attempt to revive or resuscitate an animal if necessary, but only if it is believed that quality of life can be achieved.

General Application Information
Please include a response to all required areas below.
Full Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Current Address *
Your answer
Social Security Number *
Your answer
Phone Number *
Your answer
Email Address
Your answer
Do you own or rent your current residence? *
If you answered "rent" to the above question, please list your monthly rent payment.
Your answer
List any additional members of your household that are over the age of eighteen. (If there aren't any, please write "none.") *
Your answer
Employment Information
Please include a response to all required areas below.
Current Employer *
Your answer
Employer's Address *
Your answer
How long have you been employed by the above person/organization/company? *
Your answer
Employer's Phone Number *
Your answer
What is your job title/position? *
Your answer
Annual Income *
Your answer
Total Combined Income for All Residents of Your Household *
Your answer
Please check all that apply to you. *
Required
Pet Information
Please include a response to all required areas below.
For what type of animal are you seeking assistance? *
What is the sex of your pet? *
What is the name of your pet? *
Your answer
What is the approximate age of your pet? *
For what procedure / condition are you seeking financial assistance? *
Required
Does your pet have any medical issues, take medicine, or have any problems that may be complicated by or should be known about prior to undergoing surgery? (AARFPA doesn't want anything to happen to your pet, so please tell us if there is anything that might cause a problem during surgery.) *
If you answered "Yes" to the previous question, please elaborate.
Your answer
Is your pet up-to-date on their shots? *
Vet Referral Information
Please respond to the questions below IF APPLICABLE.
Name of Referring Vet
Your answer
Name of Clinic
Your answer
Clinic's Address
Your answer
Clinic's Phone Number
Your answer
Additional Information
Please include a response to all required areas below.
How did you hear about AARF PA's grant program?
Your answer
AARF PA may use a portion of your name on its website or Facebook page to advertise the grant program. (Grants are anonymous, so only your first name and last initial or first and last initials will be used.) Please indicate how you would like your name to appear. For example: Dana G. or C. H. *
Your answer
Would you be willing to give a testimonial that AARF PA could post on its webpage? *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service